Sundowning in Dementia

Sundowning is when a person with dementia becomes more confused, restless or distressed in the late afternoon or evening, sometimes lasting into the night. It is a set of symptoms rather than a disease. Its exact cause is unknown, but there is often a trigger you can find and steps that can make evenings easier.

If the change came on suddenly, speak to a doctor, as it could be caused by something treatable such as a urinary tract infection.

What sundowning looks like

Despite the name, it isn't necessarily linked to the sun setting. Symptoms can include:

• Confusion and disorientation
• Anxiety, irritability or agitation
• Aggression
• Pacing or wandering
• Ignoring directions
• Trouble sleeping
• Hallucinations or delusions

Because these can continue into the night, the person may not get enough sleep, and neither may the people caring for them.

Who it affects

Sundowning can affect people with Alzheimer's disease and other types of dementia. It can happen at any stage but is more common in the middle and later stages. The sources we reviewed don't give a figure for how many people have it.

Why it happens

The reasons aren't well understood. Things that may contribute include:

• Tiredness: physical and mental exhaustion after a busy day
• Unmet needs: hunger, thirst, pain, boredom or needing the toilet
• A disrupted body clock: brain changes can leave someone tired in the day and awake at night
• Too little daylight during the day
• Dim light and shadows: these can be confusing or lead to hallucinations
• Too much going on: a noisy or busy environment
• Unfamiliar surroundings
• Other people's stress: the person may pick up on a carer's tiredness or frustration
• Dreams: difficulty telling dreams from reality
• Sight or hearing loss
• Depression or anxiety
• Medicines: side effects or interactions
• Health problems: such as a urinary tract infection, sleep apnoea, restless legs or incontinence

It can help to keep a note of what happens before each episode, as different triggers need different solutions.

How to help during an episode

• Stay calm and reassure the person that they are safe.
• Check whether they need something, such as the toilet, food, a drink or relief from pain. Their behaviour may be their way of telling you.
• Don't argue. Try a gentle reminder of the time, or distract them with a snack, music, a simple chore or a favourite memory. There's more on this in our guide to dementia and communication.
• If they are restless, take a walk together, or let them pace with supervision.
• Don't use physical restraint.
• If they become aggressive, keep a safe distance. Remove or lock away anything dangerous, such as car keys and kitchen knives, ahead of time.

How to reduce sundowning

During the day

• Keep regular times for getting up, meals, activities and bed.
• Get daylight and outdoor time, or sit near a window.
• Be physically active every day, without overdoing it.
• Plan appointments, outings and bathing for the morning or early afternoon, when the person is usually more alert.
• Limit long naps, especially late in the afternoon.

In the evening

• Avoid alcohol and caffeine late in the day. The Mayo Clinic suggests keeping caffeine and sugar to the morning.
• Serve a bigger lunch and a lighter dinner.
• Reduce noise and stimulation, including TV, which can sometimes be upsetting.
• Try calming activities such as soft familiar music, nature sounds, photo albums or a familiar film.
• Keep the home well lit. Close curtains or blinds as it gets dark, as reflections and uneven light can cause confusing shadows and mirror images. Cover an unused TV.
• Use a night light for dark or unfamiliar rooms.
• In an unfamiliar place, bring familiar items such as photographs.

Medicines and melatonin

Most experts encourage trying non-drug measures for sleep problems in Alzheimer's before medication. If they don't help, a doctor may prescribe something for late-day agitation, and you should talk through the risks and benefits together. It's also worth asking the doctor to review current medicines and the best times to take them.

Some research suggests a low dose of melatonin may help, alone or with bright light in the daytime. Check with a healthcare professional before trying it.

When to speak to a doctor

Talk to a doctor if:

• Sundowning starts suddenly
• You suspect pain, an infection, depression, sleep apnoea or a medicine side effect
• The steps above aren't helping
• Aggressive behaviour is getting worse

In an emergency, call your local emergency number and explain that the person has dementia.

Does sundowning affect life expectancy?

The sources we reviewed don't give life expectancy figures for sundowning. Because it is more common in later stages, it may appear as dementia progresses, but the outlook depends on the type of dementia and the person's overall health. See our page on dementia life expectancy.

Support for carers

Disturbed evenings and nights are hard on carers too, and your own tiredness can affect the person you care for. Our guide on how to support someone with dementia may help. In the UK, Alzheimer's Society runs a Dementia Support Line, and in the US the Alzheimer's Association publishes caregiving information.